Giving bad feedback or giving feedback badly?

I find myself in an educators dilemma regarding feedback in the ED. I’ll try to explain why and please do give me your thoughts.

The first thing I have to say is that I agree with Greg Henry at ICEM2012 in that the amount of positive feedback given to colleagues should exceed the criticism. Greg suggested a 10:1 as a ratio, but as a more  reserved Englishman without the gregarious nature of some of my American colleagues I’m running at about 3:1, any more than that and you get put on antipsychotics on this side of the pond. Anyway,  to be honest the offering of positive feedback is fine. It makes me feel good, it makes the trainee feel good, and I usually try to do it in public so that everyone know about it. Great, fine, let’s park the positive stuff.

My dilemma comes with the negative feedback, how to feedback when things have not gone well and lessons are there to be learned. How do we go about this and where are the challenges that we need to identify and manage.

Perhaps an example will help.

One of your radiologists calls you to alert you to an X-ray that they think was missed as it looks as though the patient was discharged. The X-ray clearly shows a fracture of the talus so you pull the notes and indeed it was. The patient presented in an intoxicated state having fallen off a kerb and was complaining of an ankle injury. X-rays were taken, reported as normal on the day by the attending doctor and the patient was discharged with crtuches and ankle sprain advice. It looks as though they left the ED that night (5 days ago). So, you do the usual stuff, recall the patient, apologise, refer etc. The patient gets an operative repair and seems to do OK. So, I’m fine with the clinical care, but clearly an error has been made here and we need to do something about it. I guess three things could have happened.

  • The doc may not be able to spot a talus fracture due to simple incompetence.
  • They looked at the wrong X-ray.
  • They only looked at one part of the X-ray (the malleoli as that’s where they suspected the injury.

My question is how to handle the feedback to the doctor who saw the patient? I’ve seen many behaviours over the years in these situations. Interestingly I have seen some seniors not bother to tell the juniors that an error has been made. Usually this is to ‘protect’ the doctor from getting upset about making an error. Can this be right? Almost certainly not as it is important to learn from error, and also to understand how error takes place (which you cannot do unless you explore the circumstances). So how are you going to go about this in a way that promotes learning and development, and what do we want to happen during that feedback process.

I’m going to be controversial and contradictory here as I must admit that in my mind there are number of things that I want to achieve whilst giving the feedback.

  • 1. Discuss and understand what happened.
  • 2. Discuss what the consequences are.
  • 3. Potentially change future behaviour.
  • 4. Ensure that this makes them feel bad (really????).

I guess you were with me up until number 4?? Why would I want a colleague to feel bad with feedback? Well, it’s not that I ‘want’ them to feel bad, it’s because I want physicians to care, I want them to understand that our actions and decisions have consequences and that part of that consequence must be for us to be able to empathise and understand the effect of error with our patients. The doctor who does not care, dismisses the error on the basis of other’s failings, who moves on rapidly without pausing for thought worries me greatly…., but on the other hand the doctor who is devastated by hearing about an error, who loses confidence and changes behaviour in an abnormal way is similarly a failure of feedback, learning and development. The point is that there is an inevitability that a bad outcome for a patient will result in the doc involved feeling bad.

So, what are we to do  when faced with a question of giving bad news to a colleague. How do we balance the conversation and experience into one that ensures colleagues reflect and pause, without leading them to despair and a feeling of belittlement? I don’t want them to leave thinking that they have been told off, that’s not the point. It’s just that there is a difference between telling people off vs telling them that everything is fine, because everything is not fine and error is a fantastic learning tool. I think learning is most effective when the error matters to the physician. I’m not sure I have this right yet, but these are my top tips.

  • 1. Try and feedback near the start of a clinical shift. It is likely that confidence will be affected and it’s good to be able to observe this in the workplace where it can be dealt with. Keep an eye on your colleagues and make sure they are OK. They will probably be ruminating about what has happened and this can affect them in many ways.
  • 2. Recognise that the senior person who gives the feedback is unlikely to be the one that the junior will then come to for support immediately afterwards. They’ll usually find someone else first. If I feedback to a junior doc then the perceived power distance (on their part) often makes it feel more like criticism than development (whatever you say). Not sure how to avoid this apart from point 6 below.
  • 3. If you can, feedback with a colleague who will also be around on shift. If I’m feeding back to a junior doc I’ll do this with a middle grade doc as well, or at least tell them that an incident has occured prior to the shift. They are often then the person that the trainee turns to for support later that day.
  • 4. Follow up in a few days time to ask if they have any more thoughts on the events and even directly ask if it has changed their practice. You will be amazed how often it does, increased referrals, increased second opinions, inrcreased investigations are common after an error.
  • 5. Buy a box of tissues.
  • 6. Lastly, never underestimate the value of admitting and publicising your own errors amongst your colleagues. We all make mistakes but there is nothing worse than feeling that you are the only one. Build a culture that shares and learns from error and you’ll find feedback easier whichever side of the conversation you happen to be on.

Oh, and the Talus fracture in this case? Well the scenario was fake, it was me who missed it. A busy night when something went wrong, I think I looked at someone else’s X-ray whilst dealing with too many patients at the same time.  I got feedback from a colleague, I felt really bad about it (still do), I learned, I got better, I shared.

Simon Carley

 

1800 – tonight we have a short audio interview with one of my colleagues added to the post about getting yourself ready for feedback. Great stuff from Nat.Natalie May on tips to giving difficult feedback

 

Comments

  1. says

    Hey Simon
    Great topic to discuss and share and thankyou for your candour.
    My tips are : make feedback a routine, a normal part of work. Define its purposes and rules. Make it two ways and encourage feedback of your own performance. The problem with feedback in medicine is that we are not taught how to give it nor receive it. Doctor culture is ingrained that , no news is good news.
    I disagree with making people feel bad as part of formal feedback. there are ways to encourage and reinforce a caring attitude but negative reinforcement is not one of them.

  2. says

    Hi Minh, great points and one that was reinforced by one of my colleagues this morning. Natalie May and I have just recorded a short podcast which I’ll upload today on this very issue. She’s got some great tips on how to ensure feedback is effective and fair.

    As for making people feel ‘bad’, then maybe it’s the wrong word. I just need to make sure that it ‘matters’. In truth I was prompted to write this post when feeding back to a colleague who, although they had made a serious error, did not seem to care. I’m not sure that that’s the sort of doctor that I would want to treat me, and not the sort of doc that I want to train.

    @davidmenzies made a good point on Twitter this morning he said
    “Also, if they have to be MADE (to) feel bad then they are in the wrong job/frame of mind!”

    I have to agree with him on that point. I must also agree with you that if feedback is routine then it is less likely to feel unpleasant. If I make a mistake then I do feel pretty awful about it and that is a normal reaction. Is it notmal not to care? I don’t think so and there is some skill needed in getting the balance right. Not all feedback is neutral, and to pretend that we can make it ‘neutral’ through just being totally objective about what happened is also unrealistic. Even if we wanted to make feedback impersonal it won’t be and as the person giving or receiving feedback we need to appreciate this. I am increasingly aware that the feedback process can have profound implications on how colleagues practice, talk, work, sleep, perform etc. and as a result I have thought much more about how we do it and what we want to get out of it, hence the blog post.

    How do you know if you’ve got the balance right? Try giving someone some positive feedback today. If they look at you like they’ve never heard you say anything like that before then your not doing it often enough!

    Remember that 10:1 or 3:1 ratio of praise to criticism .

    I really appreciate your time in replying and thanks for the PHARM blog, I’m learning lots.
    vb
    S

  3. says

    Interesting…..I’m with Minh on this one – the majority of times. We can probably all think of one or two doctors who “never get it wrong” (in their own opinion). However, they are the minority. I think the psychological profile of most doctors is of over-conscientiousness (there was something in the BMJ about that a year or so ago) and perfectionism, to a fault in many cases. Therefore, as a feeder-backer you don’t need to make the feedbackee feel bad, they will do it for themselves.

    Far more effort (IMO) needs to be expended on encouraging adaptive (rather than maladaptive) reactions in the feedbackee. This needs SMART objectives from the feederbacker – so, I want you by next shift to have a system for looking at ankle XRs that involves checking patient ID and all the bones individually and in 2 months time I want you to have used it so regularly it is second nature. This gives the trainee something achievable and reinforces the “you are a good doctor who did a bad thing” rather than “you are a bad doctor/person” differentiation.

    Just my 2p worth!

    • simoncarley says

      Cheers KC.
      As always, your comments are worth far more than 2p (at least £3.50 to be honest)
      Does reply to Minh explain it a bit more?
      S

  4. says

    Lots of Twitter traffic on this one.
    Great tweets from Javier Benitex @jvrbntz and others off line

    I feel like I’ve opened a can of worms, but I guess that’s what I wanted to do by opening the debate out to colleagues. I think some people think I’m evil – honestly I’m not!

    I think there is some confusion between giving routine feedback, critique and development tips vs. the times when as a doctor you need to talk to a colleague about something that has resulted in significant patient harm.

    That could be a missed fracture, a drug error, a death after discharge. Basically a scenario where you know that if you were that doc who dealt with the patient you know that you would feel awful. You are clearly not going to go into that sort of conversation with the same set of tools that would use if you were feeding back on something routine such as how well someone sutured a wound, or took a history. It’s just different and you need a different set of tools.

    The problem is challenging when you are the person who has been tasked to feedback to the doc who has made an error that has resulted in harm because you know this is going to hurt. Whatever you do it’s going to hurt and to be honest hurting is a normal and expected part of the process. We might think that we can feedback in a supportuive way that will leave the trainee happy and satisfied, that it’s just a learning event, but we won’t. They will (almost always) feel terrible and this is something that we should know about and put in place mechanisms to manage it.

    I take KCs point that most docs are concientious but I was prompted to post on this one following my meeting with one of the exceptions. Even then though I think the questions still arise in my mind about how can we do this as well as we can without destroying the confidence of the doc?

    Anyway, the scenario of giving feedback when patient harm has happened is a tough one and I would agree with Minh that this is an area of practice that is not taught and rarely discussed, but it should be as it’s tough. The blog post has certainly raised questions from contributors and has been read widely so if it does nothing more than get people talking that’s fantastic.

    I’m really grateful for the comments as I find this a really tough area to deal with and if colleagues have tips and advice then that’s super.
    vb

    S

    PS – the 3:1 comment was a cultural joke! I was not really advocating different ratios depending on where you live. I’m working towards 10:1…..

  5. Javier Benítez says

    Thank you for sharing. Like we discussed on twitter, it is a very complex and essential topic that needs to be covered in training programs. I agree 100% with the previous posts by KC and Minh. Attendings/Seniors doctors have to learn how to give feedback appropriately, which should be timely, specific, constructive, and respectful.

    When going into medicine, no matter what specialty, we all understand that the choices we make have good, bad, and no outcomes in patients lives. If the trainee does not understand that concept he/she is in the wrong field. From your post it seems that there are different feedbacks based on patients outcome. I beg to differ. Instead of looking at patients outcome for giving feedback, the senior doctors should look at the trainee’s attitude, depth of knowledge, willingness to learn, and change behavior.

    According to your argument if the patient’s outcome was just a missed fracture, the feedback should not make me feel as bad as if it were a missed myocardial infarction. So, if you were to give me feedback about that MI, and I cried (tears, shaky voice, head down) in front of you, you would argue my job here is done. I would say, no. Doctors are very resilient people, many people decide not to go into medicine because they would not know what to do if by their own mistake someone died. I assure you that making someone feel bad (I don’t know how you would measure that) does not guarantee that the message went through. What you need to see is change in behavior, no matter what the error is. Maybe the person needs one or a combination of: keep up with the literature, review a skill, change their attitude, or change careers. But the change needs to be behavioral, tangential and not an emotion that can just be brushed off. And, in order to build a relationship of mutual learning, and safe for the patient, the trainee cannot be talked to in a disrespectful manner, condescendingly. In the end it’s all about patient’s safety and I assure you the trainee will come up to senior docs more often when in doubt because there is mutual respect and both agree that we are in these for the patient and not for our egos. But I also do not agree on sugar coating criticism, specially in the emergency department where the pace is so fast. Again, the feedback needs to delivered timely, respectfully, specifically, and address what behavior needs to be changed.

    Again, thank you for bringing up the topic.

    Javier

  6. says

    Thanks Javier, I think I agree with pretty much all that you say. Get this wrong and the trainer:trainee relationship will certainly be damaged in all the ways that you say.

    I hope you don’t believe that I felt that the appropriate outcome from feedback is tears and belittlement. Nothing could be further from the truth on that one, but I apologise if that is the impression given. In fact I’m trying to argue the opposite and agree with you about the 4 principles you outline

    “timely, specific, constructive, and respectful”

    Can’t argue with that. I’d also add ‘supportive after the event’ as experiencing error is a distressing event.

    Great to talk/tweet/blog I said I was in a dilemma so it all helps.

    S

  7. says

    Hi Javier,
    I’ve uploaded the audio from Natalie onto the end of the blog. Her approach is similar to yours. She also makes a really excellent point about being in the right frame of mind for feedback. Much of what I have seen written in this area is about preparing the person who is about to get the feedback, but arguably it’s just as important to prepare the person giving it.

    Again, thanks for the comments.
    S

  8. Ray McGlone says

    It is OK to make a mistake, but it is not OK not to learn from them. Feedback is imperative. The only doctor that doesn’t make a mistake is the one that doesn’t see patients!
    Most docs starting off in their career are worried about complaints and I always stress to them that “it pays to be nice”. Most of the public will actually “forgive” as long as the doctor was caring and trying their best. But if you come across rushed and uncaring…. they will go for the “jugular” if you get it wrong.
    We get more Thank You letters than Complaints, so it is important to publicise these in the Common Room and keep a database (to prove to staff and management).
    Many errors are the same ones that occur on a regular basis. So all significant misses (with ECGs and X rays) are shared via E mail with staff… anonymously. I even change details sometimes to make sure it is anonymous! It is much better to learn from someone else’s mistake. The individual gets feedback separately. As the same mistakes recur I will often send out E mails from years ago to refresh the collective memory. Some are my own mistakes over the years… I have been a Consultant for 22 years now.
    Of course it is important to read the E mails. One year I sent an E mail about a missed odontoid peg fracture from the archives and the very next week a junior sent a patient home without an X ray. He admitted he hadn’t read the “Lesson of the Week”!
    Recently I had to recall one of my own neighbours due to a serious missed spinal fracture and the response was, “don’t worry we all make mistakes”. Remember it pays to be nice.
    Ray McGlone Lancaster

  9. says

    Simon, I must thankyou and the other people who have
    commented including the podcast speaker, Natalie May. What you raise is a profound cultural issue of medicine and being a professional. think about why we find giving feedback to colleagues so difficult, yet it is what we train and practice for in patient care. I mean arent we supposed to be good at counselling patients on harmful health behaviours and being able to influence their attitudes towards healthy behaviours? Yet your excellent question is why do we suck at counselling our colleagues? I think the plain truth is that some doctors are better at counselling due to their nature as well as the frequency they have to do it in their daily patient encounters. Some specialties of medicine afford you more opportunities and the right setting to do counselling than others, right? EM is probably not one of them. therefore why would an EM doc be better at cOunselling and giving feedback, than say a psychiatrist or GP? its possible but you probably need to work harder at it, with deliberate practice as your daily work affords little opportunity due to time pressures as well as the work environment. Its hard to set the right tone for good feedback and counselling in a resuscitation bay! Here are some more of my feedback practice tips: check your facts, set your environment, make it feel safe and neutral, establish understanding of the situation and what is going to be discussed, give the information you need to convey in small chunks and check for understanding and feedback at each step, clarify any points as they occur, brainstorm future solutions, agree to trial one or two for future, set review date, clarify understanding

  10. says

    Wise words Minh, Ray and others.

    We’ve taken a deliberate decision to blog about the tricky stuff as well as the topics where there ‘is’ an answer. I hope future posts generate the same amount of debate.

    I’m off orienteering, raft building and assauly coursing with my new docs tomorrow. 43 year old man vs 57 22-30 year olds. Who will win????

    Cheers,

    S

  11. Brian says

    I think one issue is that while there is an imperative to deliver negative feedback, this is not often the case with positive feedback.

    I always get a little bit of a sinking feeling in my stomach when approached with the line “Do you remember this patient?”.

  12. Gareth Roberts says

    I think the imperative on delivering “negative” feedback stems from a patient safety and educational position rather than anything else. Equally I think positive feedback and its relative sparcity come from the fact we should be doing a good job cos a “good job” isnt a “good job” in medicine its just doing “the job”
    I have to say that I think MRI is very good at positive feedback and have an incredible open “well done good job” culture for the doctors.
    Gareth.

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